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Real World Speed - Becoming a real world hygienist
both clinically and professionally
Believe it or not, it's great to be on your own! No longer
do you have to wait on faculty, fill out unnecessary paperwork,
or feel someone breathing down your neck you while you work.
Competencies and proficiencies are gone! The real world really
is different than your clinic at school. You are not forced
into a mold of practicing hygiene in a sequence that someone
is basing a grade on. You are finally able to use your educated
clinical judgment and can practice the way you want, provided
it's in your bosses agreement to do so of course! You won't
have 1.5-2.5 hours with a patient anymore, either! Yikes!
How will you ever speed up your work without sacrificing quality
of care? There are a few tips and techniques that I personally
developed for myself that was useful in becoming more efficient.
Please remember that there is a way to develop your speed
without compromising efficiency, ethics and quality of care.
To truly become efficient means you must be fast enough to
make the most out of every minute possible during a patients
time with you. You must do this and at the same time do it
within a certain time frame so that you are efficient.
Here is what I do step by step on "most" appointments.
There are many variations how an appointment could be completed.
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Greet patient in waiting room, introduce yourself and shake
hands while making eye contact. You are new to them and some
patients can be weary outside of their comfort zone and what
they are used to.
Seat patient and place bib.
Review medical history and current medication. Make sure
you do not ask "Are you on any new medications?",
but instead ask "What medication are you currently taking?"
This brings the patient into conversation because you didn't
ask a yes/no question and you are creating dialogue. At the
same time you are getting a list of their medications. Sure,
it might be listed in the chart and on the medical history
right in front of you but there could be many other possibilities
as well. They may have filled out the medical history three
years ago and forgot, or there could be a notation of a medication
change 8 appointments ago and you would have to scan and read
everything just to find it out. In regard to the medical history
form, each office has different policies, or in some cases
no policy at all! The general rule is to have the patient
fill out an updated medical history every two to three years.
Tell the patient who you are and that you are the new hygienist
to the office. Sometimes they will ask how long you have been
a hygienist (especially if you are young or look young!) and
if you feel comfortable tell them you are a recent graduate,
but I preferred to tell them "I've been doing this for
about two years." (Technically you have been doing it
for two years in college, right?)
Time: 2-4 Minutes.
Take blood pressure. I use an automatic wrist blood pressure
cuff. It's easy, and it's fast. During the one minute it takes
to read the blood pressure, you can be making notes in the
chart about the patients medical history, you can open up
the chart for easy viewing, you can place radiographs on the
view box, you can put on your mask and glasses and lay your
gloves out and you can write the patients blood pressure in
the chart because by the time you've done all that there bp
reading is finished. This also helps create discussion later
during the appointment because a lot of patients never had
their blood pressure taken at their dental visit previously.
This is one of the first things seasoned hygienists stop doing
because of laziness or because they think it saves time. Don't
compromise this important part of a dental appointment!
Time: 1 Minute
Lay patient down and do your dental hygiene exam. Check restorations
for bad margins, explore for caries, check amount of calculus
buildup (this is what I call a big "phew!" moment!
If they don't have a lot of buildup you know that the appointment
will run relatively smoothly time wise). This is also the
time to do an oral cancer screening.
Time: 3-5 Minutes
If they don't have a lot of calculus, I recommend polishing
first. Yes, that's right - I said polish first! How many of
us have been taught that in school? Polishing first is a great
way to improve your speed, believe it or not. How many times
does it take you an extra few minutes to scale the patient’s
plaque because they have poor home care? Well, you no longer
have to be the hygienist that spends too much time scaling
what in essence could be polished off. Once you are done with
polishing, not only do you have a great view of the mouth
and what's left to scale, but also any stain that didn't come
off may need to be scaled and the next step is perfect timing.
Time - 5 Minutes
Next ultrasonic the whole mouth. Regardless of calculus accumulation
research has shown that ultrasonic debridement is the best
tool we have to fight the biofilm and at the same time it
will flush out any plaque that may be located subgingivally.
Time - 5-15 Minutes
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TIP: Did you know that you can see a lot
clearer in the mirror while using the ultrasonic by wetting
the mirror? It will add a little layer of water that you can
see right through. You can use either your air/water syringe
or use the ultrasonic near the mirror for a second to wet
it.
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Hand scale and explore. Sure polishing and the ultrasonic
probably removed 100% of calculus and plaque, but I always
like to explore and hand scale certain areas just to ensure
they are smooth.
Time - 5-15 Minutes
Floss and OHI. OHI should be given throughout the appointment.
You will eventually find places during your routine that are
great times to ask questions. For instance, I always time
myself to ask a question just as I am finishing a certain
area - right before I am switching positions, moving the light,
getting gauze, or changing instruments. During that time the
patient has time to respond and I am doing something at the
same time. Try your best to not lose eye contact with the
patient for a long period as this can seem insensitive. As
soon as the patient is done speaking, you can begin working
and then discuss the oral hygiene instructions that were just
discussed. This kills two birds with one stone, so to speak.
Time - 3-5 Minutes
Doctor exam. Sometimes this is what kills you! If your doctor
tends to be slow, I would let them know you are ready for
a hygiene check at some point during you treatment. For instance,
one job I had the doctor was known to take up to 30 minutes
and I would notify him halfway through my appointment that
I was ready. There really is nothing wrong with the doctor
coming in to do his exam before you floss, etc. The majority
of dentists only check for caries and don't spend time dealing
with calculus unless it’s visible on radiographs and
supra on mandibular anteriors and maxillary buccals. Even
if there is calculus, I still doubt most dentists would have
a problem checking your patient before you are completely
finished. In offices that have more than one hygienist, a
great tip is for when the first RDH is ready for a check,
the dentist goes in to see that patient - when they are finished,
have them come to your room and interrupt you to check yours.
This helps the dentist in that they are not forced to get
up twice, it helps you not have to wait, it helps the patient
to leave without unnecessary wait times and believe it or
not, it even helps the front desk because they can walk out
two patients in a row and they wont be interrupted as much
meaning they can spend more efficient time doing phone calls,
recall, insurance, etc. This option really increases efficiency
for the entire office up to 50%! Talk it over with your doctor
and earn some brownie points for this idea. Truth is, most
dentists despise checking hygiene patients. In a recent survey,
hygiene exams was voted as the #1 thing that bugs them the
most during their work day! Any dentist would love getting
interrupted 10 times a day as opposed to 20! Oh, and by the
way - since some dentists can become irritated when you call
them for a hygiene check it's good to earn some brownie points
and treat them good when they come into you room, which you
can read more by clicking here. It's crazy that they would
even be perturbed by you coming for a check in the first place.
(Like it's really your fault you are finished on time span
besides he needs hygiene exams to keep himself busy later
so don't feel sorry for them! I don't!)
Time - 3-10 Minutes
There are times you probably should scale first. Using your
clinical judgment, if there is obvious heavy supragingival
calculus buildup on maxillary molars and lower anteriors you
probably want to scale first. Quite frankly, the majority
of your patients in private practice are on a 3-6 month recall
and generally don't have huge amounts of deposits like you've
seen in school, so if you scale first (and there several times
I do scale first), I recommend the following order. Working
following this way is based on the positioning I was taught
in school and still follow. Some of you may learn different
positioning but this works for me. The more you change positions
for both you and the patient, the more you have to change
the overhead light and the more time you waste.
* It may help to use a dentaform, or look at a picture while
visualizing this scenario.
At 12:00 Scale Lower Anteriors surfaces away from you (ex.
ML 26, ML 25, DL 24, MF 26, DF 25, DF 24)
Change position to 7:00
Scale Lower Anteriors surfaces toward you (ex. DF 26, DF 25,
MF 24, DL 25, ML 25)
(Same position) Scale Lingual LL, Buccal LR, (change instruments*)
Lingual UL, Buccal UR
Change position to 12:00
Scale Buccal UL, Lingual UR, (change instruments*) Buccal
LL, Lingual LR
While still sitting in 12:00 pick up the polisher in your
working hand and saliva ejector in other hand bended like
a candy cane. Place one gauze in your hand with the saliva
ejector. You will use the saliva ejector to suction and retract
the entire time and shouldn't need to use the mirror until
the end.
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TIP: Did you know that by retracting with
your suction, instead of you mirror, will allow you to reduce
aerosols and work faster? It will also prevent the patient
from pooling up saliva in the back of their throat and makes
the procedure much more comfortable for them. Studies have
also shown this is better for infection control due to the
aerosol reduction.
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Start by going almost in reverse order that you scaled in
with only a minor change. Polish Lingual LL, Lingual Lower
Anteriors, Buccal LL, Facial Lower Anteriors, rinse and suction.
Turn patient head toward you and polish Lingual LR, have patient
tilt head up and polish Lingual UR, Lingual Upper Anteriors,
Tilt patient head back down and polish Buccal UL, Facial Upper
Anteriors, rinse and spit.
Change positions to 7:00 and polish Lingual UL, Buccal UR,
Buccal LR, rinse and spit.
Floss
Take Mirror and air/water syringe to check distals of molars,
dry air on linguals, etc.
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TIP: Are you having trouble with your mirror
constantly fogging? Are you working on a mouth breather who
makes it impossible to see your mirror? Wipe 2x2 gauze with
some mouth wash on it and wipe your mirror. It will make your
mirror anti-fog for a long time allowing you to see clearly!
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You can work on the entire mouth both scaling and polishing
by only changing positions three times! This means it's less
time the patient has to move, less time you are fighting with
the light and more time you save to be more efficient! If
you polish first then the next order will be to substitute
polishing for the scaling and vice versus.
Remember we are not in a cookie cutter profession. Every
patient does not fit into a specific mold and now that you
have those official R.D.H. initials after your name, you can
now use your clinical judgment and critical thinking skills
to make your own decisions when and how to do something. You
will be able to determine who, what, when, why and how - most
of the time. Remember in most states we are practicing under
"supervision of a dentist” and legally they dictate
what we do, but in most circumstances they realize you have
the education to not have to "baby sit" you.
There are other ways to be more efficient even when you don't
have a patient in your room. Always go to work early and review
your charts and take notes on who needs radiographs, who will
need topical anesthetic, prophy jet, superfloss and bridge
threaders, etc. Having your room ENTIRELY set up saves tremendous
time of having to take your gloves and mask off just to pull
out some bridge threaders, for example. If they need radiographs,
have them set up and ready, the tube head out near the chair,
the lead apron over your chair and if you take them digitally,
have it already loaded so that all you need to do is stick
the sensor in their mouth and push the button.
Click for a bigger image
Take note as to who has restorative treatment that has not
been completed. Perhaps the doctor has a cancellation and
if you have a patient who needs something they might want
to come in a few minutes earlier or stay a few minutes late
to get it restored. This helps the doctor’s schedule
by helping them to produce more, and it helps the patient
not have to miss more days of work, school, etc. Also an added
benefit of this is if the patient has outstanding treatment
to be done, and the doctor has time to see him after you are
finished - move the patient into the doctors operatory and
have them do the hygiene exam in there! This allows you to
avoid the excessive wait times that sometimes occur!
This also applies to your downtime. Check the patients who
are there to see the doctor and perhaps they need their teeth
cleaned. Maybe there is a family member who needs treatment,
a full set of radiographs or hygiene recall and they forgot
to schedule it. Always, always be looking for opportunities
to increase the office production and efficacy. The more you
prove your worth - the more you are worth!
Anytime you have time with your patient while waiting for
the doctors exam should be spent building rapport and educating!
The more the patient is sitting there quiet, the more time
they have to realize they are finished and ready to leave.
If you keep them occupied you are making them feel important
and at the same time you are educating them and/or learning
about them as a person. We are dental hygienists but at the
same time we can be friends and a shoulder to lean on in certain
times. The patient could be having a bad day and by you making
one comment such as "I really like your shoes" or
something similar can be the turning point from a pessimistic
day to an optimistic one. Teach kids how to shake hands, how
smiling is not a smile unless you are showing teeth, how to
spell dental words (see kid appointment help here), etc. We
need to give our full attention to our patients! I have worked
with several hygienists that the moment they are done with
the patient and they are waiting on the doctor - they are
up front chatting with the receptionist (killing the efficacy
of two staff members now), they are on the phone with family,
or in the break area snacking. You can do this anytime, just
not on your doctor’s time and especially not when you
have patients! Be courteous and respectful of your coworkers
and have good schedule recognition. Schedule recognition is
a key trait that most dental employees just "don't get".
That means not just knowing if you are on time, but how the
rest of the office is performing. If you finished a prophy
first, are ready for a doctor exam and you are running 10
minutes early, and your co-hygienist is 20 minutes late and
waiting for a check but finished after you - its common sense
that they should be checked first. Some doctors don't even
notice this and will just go to who called them first because
"they've been waiting longer" - which is fine if
you are both on schedule, however it's not always the case.
Remember again that if you are running behind and the rest
of the office is on schedule then you will be the reason they
are late for lunch or why they might have to pick the kids
up late from school. Sure, this is okay sometimes as we will
always have days where we are stressed and behind schedule,
but making a daily habit of running late will only create
animosity with the staff, especially if the reason is you
wasting productive time!
I strongly suggest purchasing loupes. Sheervision (www.Sheervision.com)
has the best high quality loupes of anyone on the market today
and with one of the best prices. I've worn loupes from three
different companies and Sheervision has the best depth of
field, field of view, clarity and price on the market. To
read more about my loupe experiences click here (insert link).
Once you get adjusted to using loupes make a next investment
in your career by purchasing a portable LED light. I have
recently started using one and it's amazing how I ever practiced
without one. Combining loupes with a portable light has many
benefits both tangible and intangible. You can see clearly
and magnified, your posture is better and having the portable
light means you never have to use the overhead light! Anywhere
you turn and look to is now lighted and magnified! This is
just another way to work more efficiently. I can honestly
say having loupes with a portable light makes you a better
hygienist. Read the section on what you should purchase for
other items you NEED!
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